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Authorization Utilization Review Jobs in Raleigh, NC

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Part Time Pharmacy Intern P3

Durham, NC · On-site

$16.25 - $20/hr

Notify the pharmacist in the event of early fills or drug utilization review (DUR) messages. Ensure ... An Intern may receive telephone refill authorizations from the prescriber or designee. 11. Assist ...

UNC Medical Center

RN - Case Manager

Chapel Hill, NC · On-site

... utilization review, and discharge planning. The Care Manager must be a highly organized ... Identify required authorizations for post-discharge services and refer to the appropriate providers.

Harris Teeter

Part Time Pharmacy Intern P3

Durham, NC · On-site

$16.25 - $20/hr

Notify the pharmacist in the event of earlyfills or drug utilization review (DUR) messages. Ensure ... refill authorizations toprescribers' offices. An Intern may receive telephone refill ...

Team Select Home Care

Case Manager

Raleigh, NC · On-site

$19.50 - $25/hr

... their authorized representative, the agency and other healthcare providers/facilities/ outside ... Participates in clinical record/utilization review of medical records and quality assurance and ...

Team Select Home Care

Case Manager

Raleigh, NC · On-site

$19.50 - $25/hr

... their authorized representative, the agency and other healthcare providers/facilities/ outside ... Participates in clinical record/utilization review of medical records and quality assurance and ...

Flowserve

Inspector

Raleigh, NC

Reviewing and verify internal and external qualifications of suppliers, welders, NDE personnel with ... Effective utilization of CMMs is a plus Flowserve offers competitive pay, annual bonuses, medical ...

Flowserve

Inspector

Raleigh, NC · On-site

Reviewing and verify internal and external qualifications of suppliers, welders, NDE personnel with ... Effective utilization of CMMs is a plus Flowserve offers competitive pay, annual bonuses, medical ...

WCPSS

Administrator - Salary Quality Control

Cary, NC · Hybrid

Considerable knowledge of the Budget Utilization Development (BUD) system; Considerable knowledge ... authorized limits and researches potential refunds owed to or from DPI. Reviews salary data ...

WCPSS

Administrator - Salary Quality Control

Cary, NC · Hybrid

Considerable knowledge of the Budget Utilization Development (BUD) system; * Considerable knowledge ... authorized limits and researches potential refunds owed to or from DPI. * Reviews salary data ...

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All JobsAuthorization Utilization Review JobsAuthorization Utilization Review Jobs in Raleigh, NC

Authorization Utilization Review information

See Raleigh, NC salary details

$20

$41

$67

How much do authorization utilization review jobs pay per hour?

As of Aug 11, 2026, the average hourly pay for authorization utilization review in Raleigh, NC is $41.10, according to ZipRecruiter salary data. Most workers in this role earn between $32.50 and $47.21 per hour, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as an authorization utilization review specialist?

To thrive as an Authorization Utilization Review Specialist, you need a solid understanding of medical terminology, healthcare regulations, and insurance policies, often backed by a clinical background or relevant certifications. Familiarity with utilization management software, electronic health records (EHR), and payer portals is typically required. Strong attention to detail, analytical thinking, and effective communication are vital soft skills for coordinating with providers and payers. These skills ensure accurate authorization decisions, regulatory compliance, and efficient patient care coordination.

What are some common challenges faced by professionals in authorization utilization review roles, and how can they be addressed?

Professionals in Authorization Utilization Review often encounter challenges such as managing high caseloads, navigating complex insurance guidelines, and ensuring timely communication with providers and patients. Staying organized and up-to-date with evolving payer requirements is essential to avoid delays or denials. Building strong collaboration with clinical teams and leveraging electronic health record systems can help streamline workflows and improve efficiency in the review process.

What is the difference between Authorization Utilization Review vs Claims Reviewer?

AspectAuthorization Utilization ReviewClaims Reviewer
CredentialsTypically requires healthcare or insurance-related certifications, such as RN, CPC, or licensed healthcare professionalsOften requires similar credentials, focusing on insurance policies and claims processing
Work EnvironmentHospitals, insurance companies, healthcare facilitiesInsurance companies, third-party administrators, healthcare organizations
Industry UsageUsed to assess medical necessity before approving servicesUsed to evaluate claims for payment accuracy and compliance

Authorization Utilization Review and Claims Reviewer roles both involve insurance and healthcare knowledge, but Authorization Utilization Review focuses on pre-authorization of services, while Claims Review centers on post-service claims assessment. Understanding these differences helps clarify career paths and job expectations in healthcare insurance.

What is authorization utilization review?

Authorization Utilization Review is a process used by healthcare organizations and insurance companies to assess the medical necessity and appropriateness of medical services before they are provided. The main goal is to ensure that patients receive care that is effective, efficient, and covered by their health plan. This review typically involves evaluating patient records, treatment plans, and provider requests to decide if the requested services meet established guidelines. By doing so, it helps control healthcare costs and ensures quality care for patients.
What are popular job titles related to Authorization Utilization Review jobs in Raleigh, NC? For Authorization Utilization Review jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Authorization Utilization Review jobs in Raleigh, NC look for? The top searched job categories for Authorization Utilization Review jobs in Raleigh, NC are:
Authorization Utilization Review jobs near you
Infographic showing various Authorization Utilization Review job openings in Raleigh, NC as of August 2026, with employment types broken down into 1% As Needed, 80% Full Time, 16% Part Time, and 3% Contract. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution, with an average salary of $85,491 per year, or $41.1 per hour.

Senior Manager, Medical and Clinical Claim Policy and Integration

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • On-site

Full-time

Medical, Vision

Posted 11 days ago

Job description

About The Role
The Senior Manager of Medical and Clinical Claim Policy and Configuration is a senior level decision maker responsible for the content and management of Medical and Claim Policies. Also provides direction and support for system configurations as well as necessary operational assistance to ensure effective policy implementations. This individual will gain broad exposure and work closely with all business units including Medical Management, Network Management, Claims, Operations, IT, Sales and Account Management, and Legal.
*This is a remote role.
Primary Responsibilities
  • Review, update, evaluate and develop medical and clinical claims policies for Commercial medical insurance segment to promote quality, optimize utilization and cost to make them effective for the business.
  • Take responsibility and work closely with Healthcare Economics, Medical Management, Network Management, Claims, Operations, IT, Sales & Account Management, and Legal to implement policies designed to support the effective management of medical expenses and promote quality care.
  • Collaborate with IT and other departments on business and technical requirements involving policies.
  • Develop and maintain Prior Authorization list for Commercial business.
  • Manage Medical and Clinical Claim policy web content and publication.
  • Serve as the subject matter expert for Claims Editing Solution (CES) and lead initiatives involving medical and claim policy including but not limited to CES rules and configuration.
  • Prepares analyses and recommendations for medical policy updates and new code implementation for Medical Director review. Responsibilities include researching applicable CPT/HCPCS/ICD codes, benchmarking industry and payer practices, evaluating benefit and operational impacts, and providing recommendations for code handling, coverage determinations, and benefit integration.
  • Leads the digitization and maintenance of medical policies, including converting policies into electronic formats, configuring policy content within designated systems, ensuring version control and accuracy, and supporting ongoing updates to align with regulatory requirements, business needs, and operational workflows.
  • Maintains and updates JIVA automation code sets, rules, and configurations to support accurate claims processing, utilization management workflows, benefit administration, and medical policy implementation.
  • Work closely with Benefits team in configuration of new clients and working with High Dollar team for coding, PA and benefit questions
Essential Qualifications
  • Expert understanding of Medical Claims operations including medical insurance benefits, medical policy, claims policy, quality assurance, utilization review, and medical cost management.
  • Solid understanding of claim processing including pricing and code editing.
  • Strong organizational and planning skills to manage multiple priorities and meet required deadlines.
  • Good communicator, organized, and able to write clearly
  • Enjoys the challenges associated with decision support algorithms and the attention to detail it requires.
  • This job requires the ability to embed logic in narrative prose and be comfortable with numbers.
  • 5 years' experience in health care administration, managed care, or medical insurance field required
  • 2+ years' experience creating, writing, or managing clinical, claims, or healthcare technical policies and procedures is preferred.
  • Experience working with medical and claims policy reference sources such as CPT/HCPCS/ICD/DRG coding manuals, Specialty Society Guidelines, National Guidelines Clearinghouse materials, CMS and CMS Intermediary policies, and Commercial Health plans policies, among others.
  • Bachelors with an advanced or specialized degree in healthcare, public health, epidemiology, or health policy preferred (Public Health, Pharmacy, Allied Health Professional, Nursing etc.), certified medical coder preferred.
  • Familiarity working with state and federal mandates, and FDA and other regulatory requirements for medical devices, drugs and biologics.
  • Comfortable with Microsoft Word and Excel.

About
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you'll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you'll be encouraged to bring your authentic self to work with all of your unique abilities.
Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today's healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today's challenges into tomorrow's solutions.
Come be a part of the Brightest Ideas in Healthcare™.
Company Mission
Transform the health plan experience - how health care is accessed and delivered - by bringing outstanding products and services to our partners.
Company Vision
Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: [email protected]

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